Twelve Patients: Life and Death at Bellevue Hospital (14 page)

Smell’s emotive power is without peer. I had learned the smell of patients with advanced liver disease and advanced renal disease. Different infections have their own special smells, from
Pseudomonas
to
Staphylococcus
. Dying tissue, teeming with the bacterial organisms that thrive without oxygen, give the aroma of putrefaction, of dying and death. There are trillions of bacteria in a normal body, about four pounds’ worth. Many more than the normal number of human cells in an entire body. We need them to live and to function; our symbiosis with them is at the core of our being, from the mitochondrial power plants that colonized our cells a billion years ago to the bacteria that line our intestines. The balance between his former healthy body and the teeming organisms that lived within Octavio had changed. You could smell it.

By dead reckoning, Octavio had a few more weeks to live. His pain and anxiety could be controlled with a morphine pump, and a nurse could make his wound livable. If his tumor eroded into a blood vessel, then everything would conclude in a hemorrhagic spectacle worthy of a Quentin Tarantino movie. He could not sit up, and moving him would be awkward. He was a big man, two hundred pounds even after all the weight loss from malnutrition and minus a leg.

Umut volunteered to take him to Mexico. “Take him to Mexico? How would he make it?” I was taken aback. I added, for good measure, “And you don’t speak Spanish and don’t know the system. Turkish won’t cut it in DF, Umut.” I realized as I spoke that I was talking to a woman who had never taken
no
seriously her whole life.

Which is why she was standing there next to me, looking at me as if I were going to organize this final trip for the Salcedo family. I looked back. Her eyes did not blink.

“But we would need a lot of luck and preparation to make a trip,” I protested.

“Yes,” she agreed. But she did not back off.

“And who will pay for the transportation?” I asked, hoping to end the conversation.

“I will, if I have to,” she said, “but you know better than I do that it costs considerably less to take him back home than to keep him here until he dies.”

I looked at her. “Let me talk to Liliana,” I said, hoping this did not commit me to the plan.

Liliana sat in a chair sipping a cup of Au Bon Pain coffee with an untouched chocolate-filled croissant on a paper plate. I asked her how she was doing.
“¿Cómo está, Liliana? ¿Cuentéme su situación aquí en Nueva York, en Queens?”
It didn’t need much prompting for Liliana to tell me her story and how they’d ended up here at Bellevue. Octavio and she had known each other since they were teenagers. She was a little older than he was. After they started dating, they never went out with anyone else. They always expected to get married. Like all other young couples in their circumstances, they moved into the in-laws’ house. She was twenty years old. Her father had died a slow, agonizing death from liver cancer when she was a teenager. Neither of them or their families had any financial resources. It was day-to-day, every day. Everyone worked at whatever job was available to pay the bills that kept coming in for rent, for food, schools, cell phones, electricity. Chicken or pork was a once-a-week treat. Tortillas with frijoles and green mangoes were the staples. The tiny bit left over went for an emergency fund for health care. Inflation in Mexico was very simple. You had to run faster every three months to stay in the same place as the peso bought less and the government removed its subsidies for corn, gas, and petroleum. It was a kind of slow torture. A quarter of a turn of the screw and then another.

Liliana wasn’t particularly close to her own family and felt very welcome with the Salcedos, since Octavio’s parents had known her since grade school. The Salcedo house was small—two bedrooms, a living room, a kitchen, and a small workroom filled with tools and parts for automobiles and appliances. Their plan had been to buy an adjacent empty lot and build their own house. Everyone lived with their parents now, Liliana said. No one could afford to have their own place.
Multigenerational housing in perpetuity. The jobs in Cuautla had dried up years earlier. Campesinos or small farmers from the countryside had poured into the market town after NAFTA destroyed much of the export agricultural business in the adjacent states of Puebla, Oaxaca, and Guerrero. So while there was some local economic growth, it was not rapid enough to meet the exploding demand from a countryside in economic collapse. The narco economy was just beginning to lap at the heels of Morelos. You could read about Ciudad Juarez and feel how lucky you were. “It’s not happening here,” I had heard frequently. Mentally, I would add
yet
.

Brigido, her father-in-law, had a very modest automobile repair shop that paid the basic bills. No one had new clothes, and the entertainment was television and
tertulias
, long talks, with relatives and friends who lived in the barrio and made rounds from house to house. Everyone helped one another in the network. Octavio had been an excellent auto mechanic and could repair anything. He had learned his trade directly from his father, but there simply was not enough work to go around. Octavio left for the United States when their daughter, Kat, was four. For five years, he sent money back. For many relatives it was the monthly
remesa
, or money sent back by relatives in the U.S., that kept them afloat. Octavio’s sister, Barbara, received a hundred dollars a month from her husband, who also worked in Staten Island with Octavio as a house painter. This kept Barbara and their daughter Marisa in food and basics. They, too, had been living with her parents now for several years, since paying rent was out of the question. So they all lived together—the parents, the two women, and the children. Barbara and her teenage daughter shared a bed, clothes, and food; they held hands all the time and were like sisters-daughters-mothers
sobreviviendo
(surviving), she said.

The first time Liliana had come to Queens, she paid a coyote three thousand dollars. Octavio was lonely, and she decided to join him and work in the United States. They both worked and sent money home until their second child, a son, was born in the U.S. Then they couldn’t afford to look after him with Liliana working, so she decided to go back to Mexico. She was pregnant, and their third child, another son,
was born in Cuautla. Octavio had never seen him. Everything fell apart when Octavio got sick. She paid the coyote another three thousand dollars and returned to care for him.

Things went from bad to worse. First the lump in his groin, biopsies, waiting, more trips to the doctors, missed appointments, costly medicines, delays, and a diagnosis of a tumor that made no sense to either of them. None of the doctors at the local hospital spoke Spanish. They pieced together the health care that was offered, grateful for what they could get as things quickly spiraled out of control. At one point Octavio was using feminine napkins to stanch the oozing from both of his groins as he tried to continue working in the restaurant. He took dozens of Tylenol a day to deal with the pain. If he missed too many days, he would lose his work, and the years of stability and regular income would evaporate immediately. They lived in a small room in the attic of a private house off a cul-de-sac in a firemen’s community. They knew that if they missed the rent, there were many other recent immigrants from Latin America who could replace them without difficulty.

The treatment took an additional toll. Early each morning they navigated a series of buses to get Octavio to the hospital for radiation, chemotherapy, and hydration from the nausea and vomiting. She watched him get weaker and fed him fresh tortillas sprinkled with coarse salt. She cooked them on her two-burner stove. They would be warm in his hands as he ate one after another. “He says he cannot wait to have the corn tortillas from Cuautla with chunky salt, his favorite, even more than
Beso de Angel
.” She smiled. “If they had tortilla ice cream…” It was by sheer determination that she got him through the treatments. As the tumor receded, they were under the benign but false assumption that the disease had been cured. That was the time to buy a one-way ticket to Mexico, but of course as undocumented immigrants, they could not leave the country legally.

There were actually a few good months during which they celebrated the turn of events and tried to get Octavio’s strength back. But the cancer suddenly reappeared. The oozing began again, the skin broke down, and his shorts were stained. He came back from work
with long bloodstains on his legs that ran into his socks. She washed everything at night as he slept “
como los muertos
,” like the dead, and hung it to dry over the heater.

Octavio could not work anymore. The Italian family that owned the restaurant was very sympathetic and caring. The owners gave him two weeks’ pay and replaced Octavio the same day with a Mexican worker from the neighboring state of Puebla. The Poblanos had colonized New York City thirty years ago. The pioneer families sent for their relatives and established an open pipeline throughout the greater metropolitan area. Entire towns were deserted in the region as people moved to New York City, leaving grandparents behind. Gaudily painted retirement houses with new satellite dishes hoisted like masts from rooftops pockmarked the empty streets of their hometowns, a widespread scene throughout the Americas.

The exodus from Puebla had been profound and unsettling. The rural Mexican economy did not offer a viable present, much less a future. Entire industries had collapsed in the early 1990s after NAFTA was signed. U.S. agricultural subsidies permitted price differentials that Mexico could not match. Communities packed up and left for the big cities or the United States. The treaty was a stacked deck, and the Mexican worker would pay the price.

Liliana asked me what the possibilities were at this point. I was very open with her. We went over her husband’s cancer, the sheer improbability of it, the gratuitousness of it at his age without any reason. Liliana was fatalistic like most Mexicans. She did not search for reasons to explain death and illness. Bad things happen and will happen. She did not indulge in guilt or question why us or why me. She knew she would be a widow living in her in-laws’ house, managing three children, in a few weeks. The immediate pressure of economic survival would not allow the time and energy to indulge in what-ifs. Her father had left her mother a widow, and now she would follow. The symmetry was too obvious. The pauses in her comments told me more than what she had to say.

She asked me how long he had to live. “About a month,” I replied candidly.

“Can you help me get him home?” She was direct and determined. Her look was intense. “He needs to be with his family. His children. They need to see him to say good-bye.” I started to think about the meaning of a good death. A good death for him, for them, and for all of us taking care of him. This wasn’t about abstract immigrants stealthily crossing the border stealing jobs from real Americans. This was a man and his wife trying to gain a millimeter toehold on a brutal economic ladder that was created by political and economic forces beyond their control.

The goal, clearly, was to get them both home, surrounded by their family and friends, to make arrangements for his medical care. It was the best we could possibly hope for under these circumstances. I was not sure we would be able to do this, I told her, but I promised to try. When we finished we hugged each other and she started to cry. She sobbed into my shirt and tie and started to laugh nervously as she looked at me. “
No pasa nada
, it doesn’t matter at all,” I said. She pulled out her cell phone saying “
permítame
,” and called the Salcedo family to tell them what was happening. “We’re coming home,” she told them. They talked two to three times a day, but this was one of the few good-news calls. I gave Liliana my card and scribbled my cell phone number on the back.

I hoped she was right about going home soon as I opened the door and looked at her before slowly and quietly closing it behind me. I really needed to be alone now to collect my thoughts and emotions and make sense of them. It is impossible to keep withdrawing from an emotional bank account without making occasional deposits. I had an email to send, to see if it would be even possible to pull off a trip to Mexico for an undocumented, bedridden cancer patient and his wife. It needed to be soon or not at all.

I walked through the central part of the floor and cut through the administrative office space. I knew I could find an empty place to sit for a few minutes and think. As soon as I entered my office downstairs, the day would be launched and out of control, my control. The emails, phone calls, meetings, drop-in visits, real and imagined crises would intervene and would not end for another twelve hours. Better not to go there, yet. A colleague’s door was ajar, as always, and her papers were
piled everywhere, floor, desk, and chairs. Her signature five pairs of sneakers were lined up in a row. I knew she wouldn’t mind if I chilled out here for a few minutes. There were some lights on down the hall in other offices. I shut the door and sat down and turned off the light.

Medically, it was clear what had to happen. This was the easy part. Octavio was dying. He was in a vulnerable and unpredictable state that could erupt anytime. We could not control it. The failed surgeries, open abdominal wound, and amputated leg told us that. He might bleed out at any moment. I knew my friends at the Mexican consulate would move heaven and earth to help Octavio. If he could make it home, they would try to make it happen. I decided to ask them.

I called my wife and we spoke about repatriating Octavio. Diana took it in as a normal thing to do under the clinical circumstances—a logistical issue, not a moral one. She said she would come, too. By sheer coincidence, we knew the town, the context, the language, and the local rhythms of life.

The medical team would be relieved. I called Umut to tell her. She was ecstatic.

I thought about Octavio, his cancer, and, if all went well, his final trip back to Mexico. Octavio and I had the same type of cancer and had received identical treatments. Diana had taken me to Tepoztlán for several weeks to recover. It was at a sensitive time in my recovery. Through a stomach tube, I was feeding myself canned protein and calorie slurries five times a day. Cathy, my swallowing specialist, had given me a 5cc syringe to practice swallowing small amounts of water. My throat muscles had to relearn how to function in unison a drop at a time. I don’t know whether it was the air, the altitude, the sun, the volcano Popocatépetl that looked over the town, the birds, or the
corridos
that played from our neighbors’ radios, but by the second week I could swallow baby food and abandoned the plastic umbilical cord tethered to my stomach. Diana had taken me to Morelos to learn how to live again. We were taking Octavio home to Morelos to die. I sat in the darkened office for a few more minutes and let the feelings wash over me. I had changed a lot in a year. The deep dive into an automatic survival mode had cut nearly every invisible social tentacle. I now had
choices to make. Taking a patient home to Mexico to die. The only one who acted as if this were the most normal thing in the world was Liliana, who expected that we would all come through for them.